Provider Demographics
NPI:1366453193
Name:SLADE, TRAVIS D (MD)
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:D
Last Name:SLADE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2740 E 1700 N
Mailing Address - Street 2:
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84040-7783
Mailing Address - Country:US
Mailing Address - Phone:801-546-6486
Mailing Address - Fax:
Practice Address - Street 1:5475 S 500 E
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84405-6905
Practice Address - Country:US
Practice Address - Phone:800-880-3566
Practice Address - Fax:801-733-5872
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5968724-1205207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT68295OtherPEHP
UT908627OtherDESERET MUTUAL
UT107040787101OtherIHC
UT346248OtherALTIUS
UT6757OtherHEALTHY U
UTQMP000003333370OtherMOLINA
UTI32725Medicare UPIN
UT346248OtherALTIUS